Childbirth at Risk

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Childbirth at Risk
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Care of the Woman at Risk Because of
Psychological Disorders

• Prevalence of psychological disorders of adults
  in the U.S. is 26.2
• Alteration in thinking, mood or behavior

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Depression

• More women are affected than men
• CNS imbalance in serotonin other
  neurotransmitters
• Unable to process information
• Unable to concentrate
• Fatigue, sleep deprivation
• Overwhelmed by labor process
• Unworthy of motherhood
• Hopelessness

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Effect on Labor

• Unable to concentrate/process info from
  healthcare team
• May begin labor fatigued or sleep deprived
• Labor process may overwhelm the woman physically
  emotionally-no energy
• May appear irritable or withdrawn due to
  inability to articulate feelings of hopelessness
  or unworthiness of motherhood

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Bipolar Disorder

• Higher risk of suicide
• Women with a previous diagnosis of bipolar
  depression are at greater risk for developing a
  mood disorder in the postpartum period
• Postpartum psychosis is more common in women with
  bipolar disorder

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Anxiety Disorders

• Panic disorder, OCD,PTSD, generalized anxiety
  disorder, phobias
• Cause a wide range of sx in the laboring woman
  terror, SOB, CP, weakness, faintness, dizziness
  (exclude other dx)
• Labor may trigger flashbacks, avoidance behavior,
  anxiety sx.
• Severe sx to vague feeling something is wrong

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Clinical Therapy

• Provide support
• Decrease anxiety
• Orient to reality
• Sedatives/analgesia (decrease pain may decrease
  psychological sx)
• Psychiatric support

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Dystocia

• Abnormal labor pattern
• Problem with the 3 Ps
• Most common problem is dysfunctional uterine
  contractions resulting in prolonged labor
• Friedman curve 4cm in active labor-1cm/hr for
  primips, 1.5 cm/hr for multips
• Variations protracted labor arrest of labor
  (no change for 2 hours)

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Hypertonic Labor Pattern

• Ineffectual uterine contractions of poor quality
  occur in the latent phase and resting tone of the
  myometrium increases
• Painful, ineffective contractions become more
  frequent prolonging latent phase
• Management bed rest and sedation to promote
  relaxation and reducpain
• Nursing comfort measures position change,
  hydrotherapy, mouthcare, linen change, relaxation
  exercises, education

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Clinical Management

• Consider CPD (station) out of the pelvis
• If no CPD, consider amniotomy and Pitocin
  augmentation

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Active vs Expectant Management

• AMOL amniotomy, timed cervical checks,
  augmentation of labor with IV pitocin
• Expectant management Labor considered a normal
  process and allowed to progress without automatic
  intervention

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Nursing Care and Management

• VS
• Labor pattern
• Cervical progress
• Fetal status
• Vtx pressing down on cx without descent caput,
  caput increases with no progress
• Maternal hydration I O
• Monitor for infection

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Precipitous Labor and Birth

• L D occurs within 3 hours
• Maternal risks abruptio placenta, lacerations,
  PPH
• Fetal risks oxygenation may be poor-meconium
  stained AF may be aspirated, low Apgar scores,
  trauma
• Know hx, assess laboring woman for rapid
  dilatation

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Postterm Pregnancy

• Extends beyond 42 completed weeks of pregnancy
• 7 of all pregnancies in the U.S.
• Cause unknown, wrong dates
• ? Dates early sono
• Maternal risks labor induced, LGA, macrosomia,
  forceps, vacuum, perineal damage, hemorrhage, c/s
  doubled (endometritis, hemorrhage, thromboembolic
  disease)

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Postterm Pregnancy

• Fetal risks placental changes, increased
  perinatal mortality, oligohydramnios, if
  decreased placental perfusion-SGA
• IF no compromise-LGA or macrosomic, birth trauma,
  shoulder dystocia, prolonged labor, hypoglycemia
  seizures, respiratory distress, meconium
  staining-aspiration

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Management of Postterm Pregnancy

• Starting at 40 wks NST, BPP, AF index NST
  usually twice weekly
• In labor, ongoing assessment, continuous EFM,
  note AF,

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Fetal Malposition - POP

• Early labor 15, at birth 5
• Maternal risk intense back pain til rotation,
  3rd or 4th degree laceration if born OP, higher
  incidence of operative deliveries (60 of women
  will have a c/s)
• Nursing assessment back pain, abdominal
  depression, protracted labor, FHR heard laterally
• Nursing care Position change! pelvic rocking

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Face presentation. Mechanism of birth in
mentoposterior position. Fetal head is unable to
extend farther. The face becomes impacted.
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Types of cephalic presentations. A, The occiput
is the presenting part because the head is flexed
and the fetal chin is against the chest. The
largest anteroposterior (AP) diameter that
presents B, Military (sinciput) presentation. C,
Brow presentation.D, Face presentation.
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Breech

• Overall incidence 4, directly related to
  gestational age
• Frank breech most common 50-70(term)
• Single or double footling breech 10-30 (preterm)
• Complete breech 5

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Frank breech
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Incomplete (footling) breech
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, Complete breech
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On vaginal examination, the nurse may feel the
anal sphincter. The tissue of the fetal buttocks
feels soft.
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Breech

• Associated with placenta previa, oligo,
  hydrocephaly, anencephaly,multiples
• Higher incidence of cord prolapse, neonatal
  infant mortality, mec aspiration
• Entrapment, head trauma, spinal injury
• ECV (external cephalic version) attempted at 37-
  38 weeks
• Passage of mec normal in vag breech

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Transverse Lie

• Common in mutliples
• More common in multips
• Many convert to cephalic or breech by term
• If still transverse ECV may be done
• Persistent transverse lie requires a c/s after
  determining fetal lung maturity

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Transverse lie. Shoulder presentation
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Macrosomia

• More than 4500 g. (differs according to ethnic
  group)
• Obese women 3-4 times more likely
• Association with pregestational and gestational
  diabetes
• Distention of uterus, overstretching leads to
  dysfunctional labor increased PPH
• Increased risk perineal trauma, PPH, infections,
  forceps, vacuum

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Shoulder Dystocia

• ID macrosomic infant infant in labor
• McRoberts maneuver, lower moms head, apply
  suprapubic pressure
• Recognize slow descent, turtle sign, excessive
  molding
• After the birth examine for cephalhematoma,
  Erbs palsy, fractured clavicle. Neuro/cerebral
  damage

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McRoberts maneuver. A, The woman flexes her
thighs up onto her abdomen
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B, The angle of the maternal pelvis before
McRoberts maneuver. C, The angle of the pelvis
with McRoberts maneuver.
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Multiples

• Twins 3.2 of all pregnancies
• Triplets and higher 1.8
• 33 monozygotic twins genetically
  identical-highest risk for fetal demise, cord
  entanglement, twin-to-twin transfusion
• 25 of all twins are lost before the end of the
  first trimester
• Higher incidence of preterm birth

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Complications Common with Multiples

• Spontaneous abortion
• Gestational diabetes
• Hypertension or preeclampsia 2.6x
• HELLP
• Acute fatty liver (severe coagulopathy,
  hypoglycemia, hyperammonemia
• Pulmonary embolism 6x
• Maternal anemia
• Hydramnios
• PROM, incompetent cx, IUGR
• Labor cx PTL, uterine dysfunction, abn
  presentations, operative delivery (forceps, c/s)
  PPH

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Management

• Goals promote normal fetal development,
• prevent maternal complication, prevent PTD,
  diminish fetal trauma
• US frequent surveillance
• PTL prevention cervical checks start at 28 wks
  cervical measurements, fetal fibronectin
  equivocal. Bed rest and hospitalization to
  prevent PTL not supported by EBP
• Expect fundal height greater than wks gestation
• Auscultate 2 heart beats
• Wt gain 35-44
• Diet 135g protein 1mg folic acid

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Labor Management of Multiples

• c/s if presenting twin is not vertex
• External monitor A B
• Internal monitor A external monitor B
• Correctly identify A B
• Anticipate PPH

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Nonreassuring Fetal Status

• O2 supply insufficient to meet physiological
  demands of fetus
• Causes cord compression, uteroplacental
  insufficiency, maternal/fetal disease
• Most common initial signsmeconium stained AF
  (vertex) changes in FHR( late, severe variable
  decelerations rising baseline)

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Interventions

• Change mothers position
• Increase rate of IV infusion
• O2 via mask at 6-10 L/min
• Continuous EFM
• D/C pitocin if running
• Provide emotional support to woman, her partner,
  family-explanations unexpected c/s

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Placental Problems

• Abruptio placenta
• Placenta previa
• Accreta

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Abruptio Placentae

• Premature separation of a normally implanted
  placenta 0.5-2
• Risk factors smoking, PROM, HTN, previous
  abruptio10x higher risk
• Cause unknown maternal HTN(44), trauma (
  2-10),fibroids, cocaine, high parity, short cord
• Marginal, Central (concealed bleeding), Complete
• Retroplacental clot, blood invades myometrium,
  uterus turns blue couvelaire uterus- hysterectomy
• Large amts of thromboplastin are released
  triggering DIC, fibrinogen plummets

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Abruptio placentae. A, Marginal abruption with
external hemorrhage. B, Central abruption with
concealed hemorrhage. C, Complete separation
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Management

• Risk of DIC- evaluate coagulation profile
• In DIC fibrinogen and platelet counts are
  decreased, PT and PTT are normal to prolonged,
  fibrin split produces rise with DIC
• IV access (16 or 18 gauge), continuous EFM, c/s
  usually safest, T and X-M at least 3 units of
  blood, treat hypofibrinogenemia with cryo or FFP
  before surgery, may need CVP monitoring.
• Consider 2 IV lines, watch I O, worrisome if
  output below 30 mL/hour
• Clot observation test at bedside (red top tube)
  if clot fails to form in 6 minutes fibrinogen
  level of less than 150 mg/dL is suspected, clot
  not formed in 30 minutes fibrinogen less than 100
  possible

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Placenta Previa

• The placenta is improperly implanted in the lower
  uterine segment. Implantation may be on a
  portion of the lower uterine segment or over the
  internal os.
• As the lower uterine segment contracts and
  dilates in the later weeks of pregnancy, the
  placental villae are torn from the uterine wall.
  Bleeding

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Previa

• Cause unknown 1200 preganacies
• Risk factors multiparity,increasing age,
  accreta, prior c/s, smoking, recent abortion
  spontaneous or induced, large placenta
• Total placenta previa internal os covered
  completely
• Partial placenta previa internal os partly
  covered
• Marginal placenta previa edge of placenta is at
  the margin of the os
• Low-lying placenta implanted in the lower
  segment but does not reach the os

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Placenta previa. A, Low placental implantation.
B, Partial placenta previa. C, Total placenta
previa
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Management

• Vasa previa fetal vessels course thru the
  amniotic membranes and are present at the
  cervical os
• Women present with bleeding, review records, get
  us, no vag exams (unless double set-up), consider
  cervical bleeding
• If less than 37 weeks first bleeding
  episode-expectant management
• No vag exams
• Bed rest with BRP
• Monitor bleeding, pain , UC, vs, FHR
• Labs Rh, hh urinalysis
• IV
• 2 units blood available
• Betamethasone to facilitate fetal lung maturity

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Prolapsed Cord

• An umbilical cord that precedes the fetal
  presenting part cord falls or is washed down
  thru the cervix into the vagina and becomes
  trapped between the presenting part and the
  maternal pelvis
• Usually occult cord prolapse
• Risks breech, shoulder presentations, LBW,
  multips with 5 or more births, multiples,
  amniotomy

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Prolapse of the umbilical cord
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Prolapsed Cord

• Mom c/s, fetal death
• Fetus bradycardia, variable decel
• Relieve the pressure by pushing back the
  presenting part, O2, EFM, IV, fill bladder,
  Trendelenberg,knee-chest, delivery
• Women at risk not engaged SROM or AROM, bed
  rest if ROM and not engaged

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AFE

• Occurs when a bolus of amniotic fluid enters the
  maternal circulation and then the maternal lungs
• Cause unknown
• Mortality 60-80
• 10 of all maternal deaths in the U.S.

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Vigorous contractions in a woman having her
first baby can led to circumstances in which AFE
is likely to develop.-Williams Obstetrics

• Cytotec causes unusually strong contractions, AFE
  is a known risk of using cytotec on a pregnant
  woman

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AFE

• WE know that the rate of women dying around the
  time of birth has been increasing in the US for
  25 years
• What about the rate of AFE?
• Evidence suggests that AFE related deaths are
  increasing as well with a clear connection with
  increasing use of uterine stimulant drugs

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WHY?

• Wild West medicine
• Maternal mortality going up
• Slight decrease in perinatal mortality due not to
  a decrease in of babies who die before they are
  born but rather to a slight decrease in the rate
  of babies who die shortly after birth owing to
  our Neonatal intensive care.

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HX
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DES
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DES

• DES approved by FDA without testing
• 1947-1971 wonder drug 5 million US women take
  DES
• Popular regime 125 mg 700 bcps
• 1962 declared ineffective for preg but used as a
  morning after pill
• 1971 alarming rates of vaginal cancer seen in DES
  daughters

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cytotec

• off-label
• Not approved by

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Letter from Searle Warning Doctors Against
Cytotec Birth Inductions

• August 23, 2000
• Important drug warning concerning
  unapproved use of intravaginal or oral
  misoprostal in pregnant women for induction of
  labor or abortion
• Dear Health Care Provider
• The purpose of this letter is to remind
  you that Cytotec administration by any route is
  contraindicated in women who are pregnant because
  it can cause abortion. Cytotec is not approved
  for the induction of labor or abortion.
• Cytotec is indicated for the prevention
  of NSAID (nonsteroidal anti-inflammatory drugs,
  including aspirin)-induced gastric ulcers in
  patients at high risk of complications from
  gastric ulcer, e.g., the elderly and patients
  with concomitant debilitating disease, as well as
  patients at high risk of developing gastric
  ulceration, such as patients with a history of
  ulcer.
• The uterotonic effect of Cytotec is an
  inherent property of prostaglandin E1(PGE1), of
  which Cytotec is stable, orally active, synthetic
  analog. Searle has become aware of some instances
  where Cytotec, outside of its approved
  indication, was used as a cervical ripening agent
  prior to termination of pregnancy, or for
  induction of labor, in spite of the specific
  contraindications to its use during pregnancy.

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• Serious adverse events reported following
  off-label use of Cytotec in pregnant women
  include maternal or fetal death uterine
  hyperstimulation, rupture or perforation
  requiring uterine surgical repair, hysterectomy
  or salpingo-oophorectomy amniotic fluid
  embolism severe vaginal bleeding, retained
  placenta, shock, fetal bradycardia and pelvic
  pain.
• Searle has not conducted research
  concerning the use of Cytotec for cervical
  ripening prior to termination of pregnancy or for
  induction of labor, nor does Searle intend to
  study or support these uses. Therefore, Searle is
  unable to provide complete risk information for
  Cytotec when it is used for such purposes. In
  addition to the known and unknown acute risks to
  the mother and fetus, the effect of Cytotec on
  the later growth, development and functional
  maturation of the child when Cytotec is used for
  induction of labor or cervical ripening has not
  been established
• Searle promotes the use of Cytotec only
  for its approved indication.
• Further information may be obtained by
  calling 1-800-323-4204.
• Michael Cullen, MDMedical Director,
  U.S.Searle

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Hydramnios

• Polyhydramnios
• Over 2000mL of amniotic fluid
• Often occurs in cases of major congenital
  anomalies, malformations that affect swallowing,
  anencephaly
• Diabetes, Rh sensitization, infections (syphilis,
  toxoplasmosis, cytomegalovirus, herpes, rubella)

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Oligohydramnios

• Largest pocket of amniotic fluid is 5 cm or less
  on ultrasound
• Postmaturity, IUGR, renal malformations in the
  fetus

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CPD

• Cephalopelvic Disproportion
• Contracture of the bony pelvis or the maternal
  soft tissues
• Contractures of the inlet, outlet, midpelvis
• Labor is prolonged and protracted

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Retained Placenta

• Retention of the placenta beyond 30 minutes after
  birth of the baby
• Manual removal

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Lacerations

• Bright red bleeding cx, vagina
• Risks nullip, epidural, forcps, VAD, epis
• Firstdegree limited to fourchette, perineal
  skin and vaginal mucous membrane
• Second-degree perineal skin, vaginal mucous
  membrane, fascia, muscles of the perineal body
• Third-degree involves anal sphincter and may
  extend up the anterior wall of the rectum
• Fourth-degree extends thru the rectal mucosa to
  the lumen of the rectum.

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Placenta Accreta

• Chorionic villi attach directly to the myometrium
  of the uterus
• Increta myometrium is invaded
• Percreta myometrium is penetrated
• Causes maternal hemorrhage
• Tx may be abdominal hysterectomy